Depth of Penetration, Energy Levels, Length and Width of Ablation and Coagulation, % Surface Area Covered

TF:

Hey guys....just getting a seat here early!

Guest_1:

Hi everyone

Guest_2:

Hey guys this is Lornell

Guest_1:

Hi, this is Medhacker

Guest_1:

Hi Lornell

Guest_2:

Hello

Guest_2:

Tom where is your practice?

JeffreyEpstein:

Hello!

Guest_3:

If we are in the lobby can the others read our comments?

Guest_1:

Who is Tom?

Guest_2:

Hello, this is Stuart Mohr. i am a Biomedical engineer and Cutera's technical marketing manager

JeffreyEpstein:

Hey Tom

Guest_3:

tf

JeffreyEpstein:

Hi Stuart

JeffreyEpstein:

Stuart, glad you could make it

JeffreyEpstein:

Is Bob here?

Guest_2:

thank you for the opportunity

Guest_3:

Sorry guys i screwed up. i tried to go abck out and come back in so now i am guest 3. Lornell

Guest_1:

Guest_3 i can't read any other comments from you

Guest_1:

Hi Stuart

JeffreyEpstein:

i hate this guest stuff. i am going to have to contact the Chat Room company and get this "sign in" thing changed

JeffreyEpstein:

can you sign in again using your names? you just have to give your name, your email and a password

Guest_3:

i will give it a try

Guest_1:

Good Jeffrey

Guest_2:

i will try as well

Guest_1:

i will try it too

Guest_1:

brb

Lornell:

i just signed in again

Stuart:

Much better

Lornell:

As you can see it takes about 10 seconds to sign in under your name

Lornell:

Jeff, i had the Lumenis delivered last thursday. i have used it once.

Guest_2:

Not working Jeff

Lornell:

Guest 2 go back out and sign in under new account

Guest_2:

Sign in or sign up?

Lornell:

i think you are doing both

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

Medhacker:

Ok worked this time

JeffreyEpstein:

Hey Medhacker!

JeffreyEpstein:

i saw you on msmd Blog. i forget which thread.

Medhacker:

Hi Jeff nice seeing you here

Medhacker:

a few i think Jeff, that's right

Stuart:

i trust all manufacturer participants will declare themselves and company prior to the 5:00 start? To that end, for any new participants my name is Stuart Mohr and i am Cutera's technical marketing manager.

JeffreyEpstein:

Stuart, sign back in as StuartCutera.

Stuart:

Will do

JeffreyEpstein:

If you work for a company, please sign in with your company name. For example, Stuart is StuartCutera because he works for Cutera.

JeffreyEpstein:

Hi Bob!

Medhacker:

That is very nice of him

rbowen3710:

Hi Jeff!

Lornell:

Thanks for being honest Stuart

StuartCutera:

hmm, now i have two accounts with two different e-mail addresses

JeffreyEpstein:

Bob, if you recalculate the percent area covered by using area = pie x radium of spot squared, does this help?

StuartCutera:

i think it's critical to a valuable discussion.

StuartCutera:

thank you

TF:

Hey - I'm back....

JeffreyEpstein:

Thanks, Stuart! You are a good guy!

rbowen3710:

Let me work on that ... sorry, i can't do it in my head.

JeffreyEpstein:

If you work for a company, please sign in with your company name. For example, Stuart is StuartCutera because he works for Cutera.

Medhacker:

Hi Jeff, it seems like you were answering something to Bob, but i could never read his original question on my screen

JeffreyEpstein:

Bob is your wife typiing for you?

rbowen3710:

Yes, Jeff... Carolyn here typing....

TF:

Have we started discussing the various merits of the frac. co2 machines yet?

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

Medhacker:

Is there a conversation going on? i can't seem to read anything but what Jeff types

StuartCutera:

make certain to use the radius, not spot diameter. Also, if we're discussing percent coverage, are we discussing ablation coverage or total thermal damage (ablation + coagulation) damage?

JeffreyEpstein:

Any other company people in the room?

Lornell:

Stuart now you can get twice the spam. Isn't that great

Lornell:

Are we going to get started?

Medhacker:

Can anyone read me?

Lornell:

Those are importnant questions Stuart.

JeffreyEpstein:

We have people with Lumenis UltraPulse, Pearl Fractional, Sciton ProFractional, Juvia

Lornell:

Medhacker i can read you

Medhacker:

Thanks Lornell

StuartCutera:

These two numbers are very different from some co2 devices - especially with low power and long dwell times

rbowen3710:

Yes, can read you Medhacker.

TF:

Good point Stuart. i think that most of the companies - particularly the dot guys, calculate surface area treatment mathematically, without any contribution from lateral thermal spread - which i think is the wrong way to do it. It becomes important for machines with long dwell times.

StuartCutera:

thank you

TF:

Yes - medhacker, I'm seeing your stuff.

Medhacker:

Lornell if others are typing please let me know, so far i only seem to get some messages and not others. Thanks.

Medhacker:

Thanks Bob

rbowen3710:

And, yes, but we can't measure the coag -- we can only measure the ablation.

TF:

ok - how about each user summarize the pros and cons of their current machine?

StuartCutera:

i don't see Bob in the available list of attendees either

Lornell:

i see others typing but i do not think i am getting all of the messages either

StuartCutera:

lovely...

JeffreyEpstein:

Medhacker, cls and ph.cadic , which lasers do you have?

JeffreyEpstein:

i have 9 pm. Should we get started?

JeffreyEpstein:

ph.cadic, are you there?

JeffreyEpstein:

Tom has Juvia. Expert co2 User!

rbowen3710:

i use Sciton ProFractional and ProFractional xc. Pro: Ability to dial in the degree of thermal damage. Con: Slower when coag is added.

TF:

For example, my Juvia machine goes up to 7 ms dwell time - if you use that, the areas become confluent, and you are doing "traditional" co2 resurfacing, rather than fractional. While it's a nice feature to have, you have to keep the treatment goal in mind....

cls:

cls = Juvia

StuartCutera:

:)

StuartCutera:

one set at home, one set at work. Perfect work life balance

TF:

You can measure coagulation - the tunel stain method works great to show any dna damage caused by the treatment.

rbowen3710:

Thanks tf

flightdoc:

i too have the Sciton ProFractional (not the xc). Can ablate but no coag. Advantage is fairly short down time. Seems the coag adds to the redness.

flightdoc:

rb...have you noticed much difference in outcomes between ProFx and the xc?

TF:

Hey, cls. Great to meet another juvia user!

Guest_2:

This is Med Spa Guy - Guest 1 - i accidentally skipped over the "log in". My company - Sybaritic - sells an Er:YAG device called the "TriMatrixx".

TF:

Stuart: do you have data comparing fractional pearl to fractional co2, in terms of clinical results?

TF:

Hi greg

cls:

Hi TF...having fun with it!!

rbowen3710:

Haven't used xc long enough to have enough data. Treatment is much faster, 5 to 6 times so, when not using coag with this treatment head

greg:

hi guys

JeffreyEpstein:

i just forwarded Bob's email to my Journal Club Members. If you want a copy, i can send it now. Give me your email and i will forward it.

JeffreyEpstein:

Hi Carolyn. You have a lovely husband!

rbowen3710:

Hi Jeffrey. i would so have to agree with you@

greg:

tf not alot of good data from pearl i have seen, quantity i mean

JeffreyEpstein:

Tom, no ... let's start.

TF:

Right now, we're really at a disadvantage in terms of basic science. i don't believe that anyone can really say what the ideal parameters are for a given treatment. So far, it's all pretty empiric...

StuartCutera:

Am i the only industry person online? If so, i will attempt to answer honestly for all products if asked.

JeffreyEpstein:

has everyone gotten Bob's email to me?

Medhacker:

Thanks tf, i guess y'all can see me, now let's see if i can see you guys :)

JeffreyEpstein:

Yes, someone start!

Medhacker:

Excellent idea tf

JeffreyEpstein:

Medhacker, can you see others typing?

Guest_4:

hi

Guest_4:

this is Kevin Do

Lornell:

i did not like all the bleeding with the profractional

Guest_3:

Guest 3 = Sandra/Idaho

Lornell:

Can anyone read my messages beside medhacker?

JeffreyEpstein:

i see you, Medhacker

Guest_4:

Hi Sandra

Guest_4:

Hi everyone

Guest_4:

i saw yours, Lornell

Guest_4:

i am not thrilled with the bleeding from Fraxel repair also

Guest_4:

Sandra: you have the eCO2??

Guest_4:

from Lutronic

Guest_4:

??

Guest_4:

don't see anyone'styping at all

Guest_3:

Yes, the Lutronic. i love it and so do my patients!

Guest_2:

i would think that with co2 you would not get bleeding due to the cauterizing effect of co2.

Lornell:

That is the problem none of the companies want to compare themselves to another ablative device unless it is inferior.

rbowen3710:

Bleeding with the ProFractional, even quite deep, has not been problematic -- in fact, that's how I guage if the treatment is going to be effective. (SOFT method) Refer to poster that Jeff sent.

For me it tells me when others are typing but i do not always get messages from all of them.

Lornell:

Hello Kevin

kevin:

honestly, don't think anything can compare to a good co2 device

kevin:

how do you like the DeepFX so far, Lornell?

Guest_1:

Does anyone have an opinion about the ideal depth of penetration (ablation) for deep wrinkles and scars with fractional co2?

kevin:

i am down to deciding on 2 co2 devices b/c of its portability: mixto and Lutronic eCO2. Anyone having any comments??

Lornell:

Is there much going on? i am not getting many messages.

kevin:

hi Lornell

Guest_3:

Not during the procedure, i did with the Smartxide that i also tried. The Lutronic was easier to understanding what i was doing to the skin with its settings vs the Smartxide which is probably like the Lumenis product, i assume.

Medhacker:

Don't know Lornell, i am trying to figure out the same thing

Guest_3:

Is the Pearl an Erbium or a co2 fractionated device?

Lornell:

Bob, i am not sure how bleeding has not been a problem. i did multiple cases at 350 microns and they bled like stuck pigs. i had to have staff work with the pts for abput an hour to get tit to stop.

kevin:

Sandra: how much did u pay for it?? with how many years of warranty??

cls:

What type of results is everybody seeing for rolling type acne scarring?? Are you doing more than 1 treatment?

kevin:

Pearl is an Erbium-like

Lornell:

i like the options it gives me. i am not sure about the limited pulse duration (dwell time)

kevin:

Lornell, did u get the bleeding with the deepfx??

TF:

Not so much of an issue with the co2 machines, eh?

Lornell:

Hi, Kevin

TF:

Yes, Lornell - i read you.

JeffreyEpstein:

When i see Fraxel % coverage it seems to be double the DeepFx coverage

Lornell:

i think i am getting less than 10% of the messages

Medhacker:

Same here Lornell

Lornell:

Very mild compared to the Profractional

JeffreyEpstein:

15-20% is the top DeepFx coverage. i see Fraxel does 45%. i don't understand this.

rbowen3710:

Any time the zone of thermal damage is smaller than the diameter of the dermal capillaries, there will be bleeding. At least theoretically. If the treatment is not this deep into the dermis, the treatment is less likely to be effective, it seems.

JeffreyEpstein:

The reason we are having this Chat is to try to figure this stuff out.

JeffreyEpstein:

We (meaning the people in this Chat Room) need to define things and clarify things.

flightdoc:

Lornell, regarding the bleeding with the ProFractional, yes it does happen. We manage it in the office with dabbing Lidocaine 1% with epi which stops the bleeding, gives them some pain relief and

TF:

Deep holes = more bleeding!

kevin:

TOm, which issue was you talking about??

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

Lornell:

Thanks Tom. i lef that message about 10 minutes ago

TF:

If you drill a deep hole with your mtz, without coagulation, you can expect to see bleeding....

JeffreyEpstein:

Medhacker, sign out and sign in again. there must be something wrong with your connection

JeffreyEpstein:

bob is rbowen

Medhacker:

lol @ Lornell

TF:

cls: what settings do you like to use on your juvia?

JeffreyEpstein:

guest one, who are you?

JeffreyEpstein:

ph.cadic, who are you?

TF:

Only some messages are showing up for me. Guest 2: exactly right. Not a problem for co2.

Stuart:

i am sorry, i froze and could not log back in as StuartCutera

JeffreyEpstein:

DeepFx goes deep 1.5 mm. It is 75% ablation and 25% coagulation

JeffreyEpstein:

Don!!!!!!!!!!!!!!!!!

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

TF:

i think there might be a major delay in when the messages are showing up....

Lornell:

Jeff the Fraxel does multiple passes. The deep fx is giving numbers in a single pass.

JeffreyEpstein:

Lumenis says that you don't want a dwell time over 1 ms!

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

JeffreyEpstein:

Ron, sign in again as MedSpaGuy

Medhacker:

i agree tf, let's see if it's improved now

Lornell:

The first qestion we should try to answer is what is the optimal depth of penetration?

JeffreyEpstein:

Greg, you are late

TF:

rbowen: yes - by the pattern of the bleeding, you can tell how deep you are...just like taking split thickness skin grafts...

Lornell:

For me it seems to be about 10 to 15 minutes

cls:

Lately 11x11mtz, 5-7ms, 9-11w...working out quite nicely

Lornell:

Lumenis keeps telling about rox Andersons paper but i do not find it all that compelling

JeffreyEpstein:

Stuart, i think you are the only industry person. We do have the top clinical users with us tonight. Greg, Tom, Ron, Bob and others

JeffreyEpstein:

Guest 1 & 2: please sign in again under a name. just give your name, choose a password and give your email address.

rbowen3710:

Lornell, i judge how deep to go by gradually increasing the depth until i get pinpoint bleeding and then go no deeper.

TF:

Hi Kevin...how's it goin'?

JeffreyEpstein:

i seee a lot of typing but not many posts. Are you clicking "send"?

med spa guy:

i thought that with co2 you wound not get bleeding? Then how do you know how deep you are?

JeffreyEpstein:

Kevin, sign back in as kevin

JeffreyEpstein:

Hey Sandra! Great to see you!

JeffreyEpstein:

i can

Lornell:

Bob, i think you can go past where you get bleeding to get better results

kevin:

i am back

kevin:

hi Tom

JeffreyEpstein:

Guest 1,2,3 and 4. Sign out and sign back in with your name.

JeffreyEpstein:

DeepFx has no bleeding. Just ask Dr. Goldman!

Medhacker:

Jeff that very thing is happening to a few of us

med spa guy:

Does anyone have any long term results with b/a photos showing improvement with deep wrinkles or scars with co2 fractional?

Medhacker:

Better results with what procedure Lornell?

JeffreyEpstein:

Kevin, i am not talking to you until you sign back in as Kevin

Medhacker:

Laughing @ Jeff

Lornell:

With the profractional

JeffreyEpstein:

medhacker, what is your email address? are you on our Journal Club list?

kevin:

i did sign back in as Kevin

TF:

Lornell: how long does the post-treatment erythema last with an intense / high density deepFX treatment?

JeffreyEpstein:

Alright, Kevin!

canmd:

i am dealing with Asian patients. i am not sure of any one of the fractional device is better on Asian skin type ( Type 4). i do not have any fractional devicew at present. i have heard that the teh Sciton profractional is better of rdarker skin tyoe, but is this true or is this just a matter of parameters you use?

JeffreyEpstein:

Now ... who is guest 4?

Lornell:

tf - i can't tell you yet i did my first fairly agressive treatment yesterday.

kevin:

i think there is a major delay in relaying our messages

rbowen3710:

This is how one can be reasonably assured that patients will not "bleed like stuck pigs".

9 users are typing. We should see 9 messages. Are all messages getting through?

Stuart:

if you look at Pearl Fractional - it is a 300 micron spot and 40 microns coagulation

Stuart:

by area though, it's a 300 micron circle inside a 380 micron circle. the area is about 62% ablated

med spa guy:

Did everyone get my earlier question about the "ideal" depth of ablation (penetration")? Nobody has an opinion?

Stuart:

i agree with Lumenis. This is from the original days of co2 resurfacing that showed greater pigmentary complications with increased thermal damage. Above about 700 microseconds pulses start to lose thermal confinement and increase thermal damage without increased ablation

Lornell:

Bob, i do know one doc that is using 1 ml of epi 1/1000 in 500 cc of sterile water and that seems to help with the post procedure bleeding.

Stuart:

that is why we use a 600us pulse duration, but also why we didn't select co2

flightdoc:

canmd: i have treated 2 (yes, very limited numbers) of asians for acne scarring with the sciton profx and have (so far) not have any hyperpigmentation.

Stuart:

typical depth of treatment we've observed for best results and best downtime is about 600-800 microns

Stuart:

once that deep, density becomes a more important variable for most treatments

Stuart:

which paper? He's published a few...

med spa guy:

Did most of you receive a chart i e-mailed earlier today with estimated depth of penetration (ablation) for Er:YAG? Does anyone have this data for co2?

Stuart:

Bob, does this mean with the sciton that you're typically around 150-300 microns?

TF:

Doesn't the mixto have that weird parameter stuff, where you can't independently vary the density and dwell time?

TF:

Pearl is ysgg, i believe. Totally different.

Lornell:

On the idea of ideal depth. there is some histology done by Jason Pozner that started to show scar cells replacing the normal cells at 1000microns. So anything past 1000microns may be useless and increasing the likelyhood of causing problems

canmd:

fightdoc, can you share with us how much improvement you can see with these 2 patients? i have patients who have Fraxel Restore at other clinic. Some had Alma Pixel, i do not think the result is very impressive. MInd you, one patient only had 2 Fraxels. The Alma Pixel patients had 3-4 treatments as far as i remember,

TF:

Acne scars are difficult. 2 - 3 treatments. Maybe 50% clearance.

cls:

i am not getting many messages..I already signed in and out

Stuart:

bleeding is not a good comparison when trying to compare different technologies. Erbium bleeds very easily vs. ysgg or co2

TF:

Me too, Lornell. There are some technical issues going on here that i don't understand.

JeffreyEpstein:

Bleeding occurs with co2 when vessels are larger than the ablation plus coagulation (larger than 120 microns)

JeffreyEpstein:

When we are done, we should all check the transcript which will be posted on MedicalSpaMD. i will contact the Chat Room Company. We have to make sure all comments get through.

Lets do a test. Everyone type the word yes and send. We should get 12 "YES"s

med spa guy:

Flight Doc: Have you seen similar results with deep wrinkles?

JeffreyEpstein:

yes

med spa guy:

Yes

cls:

yes

JeffreyEpstein:

does everyone see my "yes"?

TF:

i haven't had any bleeding issues....but of course, my treatments are not as deep as the DeepFX or fraxel repair

JeffreyEpstein:

i have seen zero "yes"

flightdoc:

in my experience I've seen bleeding between 150-200 microns with profx (erbium, no coag). for fine lines, texture that is about where i go. Scars i go deeper.

JeffreyEpstein:

can you guys see me?

cls:

i see 2 "yes"

JeffreyEpstein:

everyone type "yes" if you see this

JeffreyEpstein:

hello!!!!!!!!!!!!!!!!!!!!1

kevin:

yes

canmd:

yes jeff

JeffreyEpstein:

kevin

cls:

yes

JeffreyEpstein:

lornell

JeffreyEpstein:

tom

med spa guy:

Yes

flightdoc:

i actually do more combination treatments now. profx with bbl (ipl) if I'm addressing texture and color (pigment/redness)

Stuart:

hello?

med spa guy:

i saw a "yes" from Jeff and cls.

med spa guy:

i can see you, Jeff

flightdoc:

I've moved away from the combo of micro laser peel + profx due to more down time.

flightdoc:

yes

Stuart:

i agree, that is the reason for asking the depth. What I've observed in our studies and Fraxel's is that 600-800 microns is frequently around the depth for best results - obviously all cases vary, but this is a question I've been trying to answer

Stuart:

i don't with co2, but the Cutera site has pictures with dates and parameters for Pearl Fractional

TF:

i think the coagulation is probably the important part....getting the right amount of heat into the dermis (but not too much to give problems)

Stuart:

Lornell, what depth do you typically use?

Stuart:

and what density?

Stuart:

Sorry, Lornell, do you use the Sciton or the UltraPulse?

flightdoc:

Med spa guy: with deeper wrinkls, if i can get the patient to give me down time, I'll do profx and laser resurfacing for best results. if not, then I'll do profx but plan on more treatments.

TF:

i don't agree. What is their evidence?

flightdoc:

plus botox where appropriate

Stuart:

are any?

TF:

Mid-papillary dermis, i would say.

Stuart:

Jeff, i still have not seen any messages since your post about 1 minute ago

med spa guy:

i know that the Sciton Er:YAG can modify the pulse duration to change the percentages of coag vs. ablation. Can any of the co2 fractional devices do this?

i did answer that. Total depth of treatment appears to be about 600-800 microns deep.

flightdoc:

yes

TF:

When they were designing parameters for vein treatment, trying to keep the times under the thermal relaxation time, that would be more critical. If you want to get more heat into the dermis, use a longer time, and get more coagulation and hence, more result.

TF:

i had just been hitting return

TF:

Lots of users typing....not seeing messages.

JeffreyEpstein:

i think the Chat Service is messing up. We need a better chat room arrangement.

TF:

hi Kevin.

JeffreyEpstein:

We may have to use "go to meeting" next time.

TF:

Oh no, not the dreaded goldman reference!!

Stuart:

for most treatments. Does this match other's experience? i state this from our clinical experience and from published articles i can read from other companies

JeffreyEpstein:

can anyone see me?

Guest_1:

yes

med spa guy:

Yes, Jeff

Medhacker:

Lornell the profractional used with what goal? acne? scars, wrinkles etc?

JeffreyEpstein:

If you see this, type "yes"

JeffreyEpstein:

me too

JeffreyEpstein:

no one can see me

med spa guy:

Yes

Medhacker:

Yes Kevin something is going on with the messages

cls:

yes

JeffreyEpstein:

can you see me?

med spa guy:

Jeff-- i can see you

TF:

Great question, medspa guy. i think most fractional machines have a hard time with deep wrinkles, especially compared to traditional co2.

JeffreyEpstein:

no one can see me. good night. send me an email at Jeff4459@aol.com if you want to be in our Journal Club

Medhacker:

No Jeff that is what some of us are noticing a while back, not all messages are getting through

TF:

No, Jeff. Hardly any messages get through

flightdoc:

i saw yes form Jeff, Kevin, canmd

flightdoc:

and med spa guy

TF:

Stuart, how deep can pearl fractional ablate?

TF:

i answered that - mid-papillary dermis

Medhacker:

So canmd you are not really getting good results?

TF:

600-800 microns makes sense. 1.5 mm (deep fx) does not.

rbowen3710:

Jeff, as i stated in my email earlier, Fraxel calculates their percentage of surface area very differently and it is consistently about twice as much as other systems.

Medhacker:

tf would you say only 50% improvement in acne after that procedure is an insufficient result?

Medhacker:

cls i think everyone is experiencing that delay problem

TF:

Somewhere in my files, there's a paper - i think Vic Ross did it, looking at depth of Co2 penetration with various parameters.

Medhacker:

yes

Medhacker:

i do Jeff

Medhacker:

Did you see my yes Jeff?

rbowen3710:

Depth of treatment depends on the problem being treated and patient's skin characteristics.

Medhacker:

i saw yours Med spa guys' and cls's

Medhacker:

i can see you Jeff, try the yes test again just for shizzle

Medhacker:

yes

Medhacker:

i only saw my Yes

med spa guy:

This is quite difficult withe the delays and all. There has to be a better way. If anyone knows a superior service, please let Jeff know.

TF:

Lornell: i would agree with the 1000 micron limit. Probably should be even less. i worry that deepFX can go too deep for those who are not savvy.

rbowen3710:

For example, epidermal problems can be treated superficially without any bleeding. But to get dermal remodeling, you have to be deep enough which will necessarily involve some bleeding

Medhacker:

Jeff did you not see my second yes?

Guest_1:

If anyone else is out there... is the Pearl an Erbium laser?

flightdoc:

what are people doing for pain management at depths of 600-800. i know we push the limits with topical at 300-400.

Medhacker:

You think right Jeff, it is messing up , i can see you

Medhacker:

Hahaha

med spa guy:

Nobody has ever seen a formula or table for converting fluence with co2 into depth of ablation? i have it for Er:YAG.

rbowen3710:

Med spa guy, if the zone of thermal damage is less than the diameter of the dermal capillary it will bleed. So if you are deep enough in the dermis even with co2 you can expect to see some bleeding.

Medhacker:

Yes Yes

Medhacker:

Peek a boo Jeff

med spa guy:

Jeff and several others have the Deep Fx. Perhaps they can do some punch biopsies and we can determine depth (and width) of ablation and coag for real???

TF:

Thanks Jeff. THere are definitely chat room tech issues that need to be fixed. The time delay is too long, and too many messages don't get through. But at least we had a good turn out tonight!

TF:

Good night, everyone!

rbowen3710:

Lornell, i agree, but if people are worried about the bleeding issue, then this is a way to minimize it, still be effective, but perhaps with multiple treatments.

Stuart:

We have multiple users in Japan with Pearl Fractional and are also seeing nice results. i think you always want to treat asian skin more conservatively to reduce edema and erythema

Medhacker:

i do med spa guy i tried PMing him, hopefully i can be of help

med spa guy:

tf: If you can find the reference i would love to get it. i am working on a "treatise" on fractional resurfacing.

med spa guy: can you summarize your chart easily for those of us that did not see it?

Stuart:

tf, i don't know what your statement reffered to so I'm sorry, i cannot comment. Yes though, it is ysgg and is totally different from co2 and Erbium

med spa guy:

Jeff signed off about ten minutes ago. i am typing this at about 10:40 est.

med spa guy:

Medhacker: i saw it.

Stuart:

Alma pixel typically ablates about 50 microns per pulse. To get results, a user should stack about 5-10 pulses in each location prior to moving

med spa guy:

Jeff is gone. Has anyone had a problem trying to use 1000 microns depth?

Medhacker:

It arrived here at 10:50 med spa guy

rbowen3710:

Canmd, because the ProFractional is Erbium 2940, for treating Asian and darker patients, the density can be decreased and the heat limited by not adding coag. This leads to less pih. Dr. Bessinger in Hawaii and Dr. Baker in Memphis have a great deal of experience with this.

rbowen3710:

Med spa guy, yes thanks, got it. Don't know about co2.

med spa guy:

Er:YAG is 2940 nm. Er:Glass is 1540 nm. Pearl is ysgg-- close to 2800 nm. Not as perfectly absorbed by water as Er:YAG. But very close.

med spa guy:

Try putting in the time of your comment so we can see what delay is going on. It is 10:43 est for me now.

Stuart:

Jeff, co2 diameter of spot is 120 microns. Ablation is another 75-150 on each side depending on the device for a total diameter of about 270-470

med spa guy:

Greg: Hello. You are strangely silent tonight. Are you getting these comments??

rbowen3710:

Stuart, for treating pigment and fine lines. For scars, much deeper, 400 to 600 typically for acne. As deep as 1500 on burn scars!!

Guest_3:

The day after the procedure, i see that the face has bleed and weeps. i use a 120 um tip for most of my patients want skin tightening.

rbowen3710:

Canmd, my results similar to flightdoc. Can email you my poster with pictures if you want. p.s. Yes.

rbowen3710:

Yes.

med spa guy:

Don't forget about the dreaded pih. My company has seen very little interest in Japan and most Asian countries because they are terrified about pih.

rbowen3710:

i can see you Jeff.

Medhacker:

Hi 10:57 est here

rbowen3710:

Yes yes yes

rbowen3710:

Flightdoc, me too.

Guest_3:

i know my rep for Lutronic had his pick of representing for either company and he choose Lutronic because he thought this machine was a better product. i don't have knowledge of the MiXTO, though.

Stuart:

some CO2 units (DOT and Affirm) use larger spot sizes and longer dwell times so add about 200-300 to the spot size for total diameter observed by histology

Stuart:

yes

Stuart:

yes

med spa guy:

Medhacker: Do you want the chart of ablation depth with Er:YAG?

med spa guy:

It'

Guest_3:

i would like to know how the settings compare because i don't have dwell and pitch, i have density, pulse energy, static or dynamic, among others that i can make the machine stamp faster.

Guest_3:

i wonder if some people are off in a private chat?

rbowen3710:

Flightdoc, doing bbl first may activate heat shock proteins and promote faster healing and more efficacy.

Stuart:

i saw it and responded about 60 seconds ago. There is some problem. i saw about 2 others

StuartCutera:

if not, i cannot see the other attendees

rbowen3710:

Can see you Jeff.

rbowen3710:

Yes.

StuartCutera:

likewise

Stuart:

We use Pearl to treat conditions that the ProFractional improves at the depth of bleeding

Stuart:

yes

rbowen3710:

Sorry guys, gotta run. Past my bedtime! See you next time.

Stuart:

Pearl Fractional is for deeper indications

med spa guy:

s a simple chart based on the statement in the Goldman/Fitzpatrick text based on the ablation threshold for Er:YAG -- that you get x microns of depth for every x J/cm2 used.

StuartCutera:

very much so. It understates the degree of thermal damage and potential coverage and later risk due to potential thermal overlap

coag can be measured easily by histology. If this is not available, i would be concerned

Stuart:

have you still not seen my yes?

Stuart:

i sent the original yes about 3 minutes ago

Lornell:

tf - i know lumenis is always talking about a short pulse duration but that is all based upon complete ablation and not fractionated treatments

Medhacker:

Hahaha at stuart 11:04 pm est

med spa guy:

Stuart: It sounds easy and logical to simply stack the pulses, but with an unknown amount of thermal spread (coag) while you are punching holes deeper you will robably be severely overheating the epidermis. i would love to orchestrate a few "side by sides" with these various devices. It would be very interesting.

StuartCutera:

if it is a matter of the physician not knowing which is displayed, the company should be able to answer.

StuartCutera:

Ready

StuartCutera:

are there a total of 9 people in the room and no other industry individuals?

Medhacker:

7 now stuart 11:06 pm est

Stuart:

Flightdoc, we have many customers doing the same sort of thing. Combination protocols are always beneficial as many work in slightly different ways on a wider range of applications and can provide a greater patient expereince and benefit in a single treatment

StuartCutera:

exactly. any company should have histology to justify claims for treatment

Stuart:

flightdoc, this is interesting. We do not see any increase in downtime when combining a Pearl treatment to ~90 microns and a Pearl Fractional treatment to 700 microns

Lornell:

i guess i am going to throw out my 2 cents. i think we are going to find that the following parameters are going to be the best with the least sideeffects with a fractionated co2. Depth of penetration and coagulation is going to be between 600 to 800 microns. Ideal dwell time (pulse duration) will be between 0.8 and 3 msec. And ideal density for deeper penetration will be 20 to 40%. This is just my opinion with all of my recent research.

Lornell:

yes

StuartCutera:

Residual thermal damage (rtd) has it's advantages and disadvantages. Too much and there is more debris to clear taking longer healing. TSome however provides hemostasis and increases several hsp responses

greg:

different wavelenth different charastics also

med spa guy:

Greg: Are you hiding? Maybe you are not getting these comments??

greg:

tf, are u changing to fully ablative in problem areas during tx?

StuartCutera:

Balancing this and maximizing ablation while maintaining is why we chose co2

greg:

hi kevin, long time!

med spa guy:

Stuart: The only co2 with a 120 micron diameter i know of is Deep Fx. Most of them are 300 microns or larger in diameter. One of the articles Jeff sent earlier today mentioned the fluence of the micro-beams -- but i can't imagine how they measure that. No energy meter on earth is capable of that. It is now 11:00 pm est.

greg:

fraxel goes to 1.6mm ablation, to deep you get blood

StuartCutera:

i don't know of many split face cases. i only know of one vs. the dot and Pearl and Pearl Fractional are favorable at this time. The patient is a 2 weeks post currently

Stuart:

the downtime is dictated by the more aggressive Pearl Fractional procedure making the Pearl procedure purely beneficial to the customer

greg:

not much haet with pearl, correct?

Medhacker:

i read your message sent at 11:00pm at 11:09 pm med spa guy

greg:

me too lornell

Stuart:

tf, i think ablation is more important than thermal. Fractional non-ablative lasers had more thermal damage than any fractional ablative and did not achieve the same results

Medhacker:

This chat has dysphagia lol sent at 11:10 pm est

greg:

jeff we need a bigger chat room with real time. we can work on this

med spa guy:

Guest 3: Pitch is similar to density. You may be able to translate the specs.

Stuart:

It will be interesting to look at a transcript of this discussion as i think there are many parts i don't see.

med spa guy:

Jeff signed off a long time ago. It is now 11:03 est.

med spa guy:

Stuart: I see it (11:06 PM)

greg:

kevin did you look at dot, its like mixto but more versitile with parameters

greg:

guest 1, it depends on where

med spa guy:

Perhaps Jeff can get the answer from Lumenis. i hear they love him!

Medhacker:

i meant aphasia hahaha sent at 11:10 pm est

Stuart:

The Sciton yag states this, but if you look at histology stains, coagulation in a fractional column is not the same with Coag mode as it is with absorption. Absorption creates a uniform thermal zone around the ablation column due to light scatter. Coag mode with erbium creates a bulb of coagulation at the bottom of the lesion, but not along the edges where bleeding occurs

Stuart:

i can, but i have no idea when you typed your message

greg:

i think the bleeding is fron too large spot size

StuartCutera:

Our advisory board has experience with other devices and are all favorably impressed with the Pearl Fractional. Pearl really does not compete in the fractional ablative space. It competes in the fractional non-ablative space

greg:

larger deeper spot will get larger vasculature, not enough coag to stop it all

Stuart:

Thank you everyone, appreciate the chance to take part in this conversation. Please feel free to contact me with any questions at smohr@cutera.com

med spa guy:

Stuart: i am both "industry" and also a quasi practitioner/med spa owner. But not an md.

greg:

jeff some go to 100%, fully ablative

Lornell:

i saw 4 "yes"

Lornell:

yes

StuartCutera:

tf, i agree. Epirically though, fractional non-ablative has more thermal damage with larger spots and deeper injuries, but does not provide the same degree of improvement as fractional ablative treatments

StuartCutera:

the difference is ablation

greg:

i agree rbowen3710, that is not theory but fact

Lornell:

i entered this message at exactly 9:25

greg:

lornell we should start your suggestion with where and why, skin different thickness around facial anatomy

StuartCutera:

low power and long dwell time fractional co2 devices are actually almost exactly the same as non-ablative devices. most are about 90% non ablative and only 10% ablative

Lornell:

i am just getting started but i wan to be about 800 microns for the more agressive procedures. i am thinking about going to about 25% coverage

StuartCutera:

Lornell, i see your message

med spa guy:

Lornell: i believe you mean 9:25 cst. i saw it at 10:16 cst. This is bizarre!

Lornell:

The DeepFX/ActiveFx

greg:

jeff, i have been here for 45 minutes

StuartCutera:

higher power short pulse co2 lasers are about 20% ablation, 80% coagulation

StuartCutera:

Pearl Fractional is about 60% ablation 40% coagulation

Lornell:

tf, Exactly. That is even more important for the Fractionated devices. But the question is how long of a dwell time is too long?

greg:

med spa guy, depth is estimated by set parameters

Lornell:

Jeff, i can see you.

Medhacker:

What a weird chat - 11:16 pm est

greg:

med spa guy, i have then for fractional erbium

StuartCutera:

Erbium is about 90% ablation 10% coagulation - regardless of coag or not. Coag changes the bottom of the column, but not the edges

Lornell:

Medhacker, i guess i am talking about more agressive treatments. Modrate to deep rhytides, solar elastosis and acne scarring

StuartCutera:

the edges are the primary source of bleeding, contraction and thermal stimulation

greg:

med spa guy , i have one for co2

greg:

tom you are right about the mixto

med spa guy:

Note to all: Jeff signed off at about 10:30 est.

Lornell:

tf - i agree that the depth of penetration listed by Lumenis, fractionated Pearl and Fraxel is over kill and all about marketing.

Lornell:

Tom if you find that paper from Ross let me know.

StuartCutera:

Hello? i don't see any new messages

Lornell:

yes

StuartCutera:

can you see this?

StuartCutera:

you will always have some telangiectasias that are larger than the diameter of the coagulation zone. These will have a hole in them and bleed

StuartCutera:

i think one reason is the risk of pih. Greater thermal damage has always been the achilles heel of co2

Lornell:

i do like the fact that with the lumenis i can basically do a deeper treatment say to 700 micrions and 20 to 30% density and then do a superficial fractionated coverage to about 150 microns and 75% coverage. i like the flexibility of the 2 spot sizes.

StuartCutera:

Treatments to comparable depths and aggressivness show about a 15-17% rate of transient pih in fraxel studies. a Pearl Fractional study with 2x the patient population (about 28) has a 0% rate in the same patient population

Lornell:

i have an acne pt coming in for a treatment in the next few weeks with a lot of baxcar scarring. i think i am going to use my erbium to take the edges down and then use the DeepFx over the entire area probably down to about 800 microns.

StuartCutera:

The other benefit is the ability to combine Pearl and Pearl fractional in a single treatment. All fractional ablative devices are fractional so benefit from healing advantages of fractional, but suffer from coverage limitations of fractional

Lornell:

Ron, the problem with the CO2's is the variable spot sizes. You owuld have to figure it out for each spot size. i am also seeing a wide variety of penetration depths on different pts as well as differnt areas of the body.

StuartCutera:

Pearl and Pearl Fractional together allow a single treatment with 100% coverage and deep fractional ablation. Brian Beisman was the first to perform this combination. The great thing is the two work complimentary and do not change downtime

Lornell:

My goal with this is to have a sfew treatments as possible safely.

med spa guy:

Lornell: i still can't imagine how you can justify paying $170,000 for a device that only treats essentially one or two primary indications. Are that many people interested in wrinkles and scars??

StuartCutera:

Does this description make sense?

Lornell:

Ron - i got your timed message at 1057 eastern time

StuartCutera:

Kevin, to be fair, there are no comparative studies to make that assertion

Lornell:

It is 10:56 est

StuartCutera:

neither pro nor con, and full coverage multi-pass resurfacing is not a proxy for fractional resurfacing

Lornell:

i am oing to go to bed. Talk to you guys by e-amil tomorrow.

StuartCutera:

we do know that the history of co2 is one moving from long pulse durations to shorter pulse durations in an attempt to limit thermal damage. Never did it reduce results. The only alternative to the best co2 pulses with several hundred microsecond dwell times to limit thermal damage was erbium with almost no thermal damage

StuartCutera:

what I've been able to find, and our experience, is most studies show depth in the 600-800 micron depth range for many wrinkles and scars. Some treat to ~1mm for greater scars